Strings attached? Corporate influence and fractured autonomy in medicine

Picture credit: Santanu Sen, via Flickr

Since Apollo launched in 1983, India has seen a pronounced expansion in its corporate healthcare sector. In this blogpost, Dr Indira Chakravarthi and Dr Ben Hunter highlight findings from their recent article on a corporate-led transformation of healthcare in Maharashtra. They point to doctors’ growing reliance on employment in the corporate sector, the constraints this places on professional autonomy, and signs of a deepening divide in status between precariously employed juniors and ‘star doctors’.

Corporate transformations

In Maharashtra, the past two decades have seen a significant shift in the form of healthcare provision. One of the most immediately visible changes is the growth of large corporate hospital chains like Apollo, Max and Narayana. But there have also been changes in other parts of the healthcare provision sector: small- and medium-sized hospitals (often practitioner-owned), unable to match the range and sophistication of corporate hospitals’ services and to meet changing patient aspirations, have closed, merged or been taken over by corporate chains; while a series of charitable hospitals facing similar challenges have entered into leasing or service contracts with corporate chains.

This trend is closely entwined with a shift in medical employment opportunities. The expansion of private medical education in India has led to a cohort of heavily indebted graduates in a crowded marketplace for employment in specialist fields and in urban centres. Government hospitals hold dwindling appeal for specialists and other doctors who cite difficult working conditions and little enthusiasm for work in remote and under-equipped facilities. Small practitioner-owned hospitals, once the obvious route for medical graduates, are impossibly expensive to establish and operate; few are equipped to handle insurance schemes and lose those patients. Employment in the corporate chains, either as full-time employees or as visiting consultants, is now a key feature of the sector.

Strings attached

Work in corporate hospitals has various attractions for prospective employees. Doctors’ pay and conditions seem generally better than in other parts of the healthcare provision sector, there is significant prestige associated with work in a renowned chain, and a visible security presence that provides some comfort at a time of growing concern with attacks on health workers. Added to this, clinicians are in many ways released from the day-to-day management concerns that would have absorbed their time in running and managing their own practice.

Yet many of these junior posts are precarious, with rolling contracts that can be readily terminated at short notice, in departments that can be closed if felt by managers to be generating insufficient revenue. There are accompanying behavioural expectations for clinical work and use of individual performance targets is widespread, placing new constraints on professional autonomy, particularly for early career doctors. Hospitals have adopted treatment protocol which on the one hand might standardise practices and prices, but which also constrains clinical autonomy and opportunities to request fee waivers for users felt less able to pay.

Professional divisions

The broad trend towards employment in corporate chains in Maharashtra is characterised by deepening inequalities between different groups in the medical profession. One group is the newly qualified junior doctors with large debts, few employment opportunities and precarious working conditions. They face significant competition to obtain posts and then once in-post they must meet the expectations of their managers’ financial imperatives. Another is the ‘star doctors’ – the renowned specialists who straddle the roles of medical practitioner, entrepreneur and celebrity philanthropist. They attract wealthy users to the hospitals where they practice and so can occupy visiting positions with multiple hospitals in return for lucrative payment packages.

These changes represent a two-fold reordering of power for the medical profession in Maharashtra. First, there are new expectations and pressures from the corporations, managers and service users whom medical professionals encounter in the private healthcare sector. This is challenging the traditional authority and autonomy for the medical profession and echoes similar trends that have taken place in other countries since the advent of New Public Management principles in the 1980s. The commercial pressures instilled by corporate structures and management are particularly concerning in a context where health needs too often appear to be secondary to commercial interests, as in ‘cut practice’ (cash-for-referrals).

Second, a new elite of super-specialists has emerged at the expense of the senior general practitioners who have historically been more prominent in this area. This exacerbates historical stratifications based on class and caste, as differences in who can enter the prestigious medical schools and afford postgraduate specialty training carry through into employment opportunities. It raises questions around the long-term effects of this deepening division, and whether medical associations and government agencies can and should be doing more to address this.

This work was part of a research project: Practices, regulation and accountability in the evolving private healthcare sector: lessons from Maharashtra State, India. The project was funded by the UK Joint Health Systems Research Initiative. The study examined key transformations in the private hospitals sector in two large urban centres of Maharashtra state, Mumbai and Pune, and the implications for medical and institutional practices. Data were collected from semi-structured interviews with 43 respondents, including medical practitioners, with experience and detailed knowledge of healthcare in Maharashtra, and from a witness seminar on the topic of transformation in Maharashtra’s healthcare system. For more information on the project click here. For a transcript from the witness seminar, click here.